No such thing as a Free Lunch

Drugs and Poppies

I ate my last free lunch this month, the inevitable result of years of planning on doing just that. I had just needed a little push.

But I get ahead of the story.

Sally’s blood pressure was very high. When I last saw her (just over 6 months ago) it was perfect. I remembered congratulating her efforts at that visit. “Your blood pressure is like a teenager’s!”

What had happened?

I entered the exam room and asked Sally how she was feeling. She admitted to headaches and more fatigue.

I suggested ordering some tests and doubling her blood pressure medication.

“No, please don’t,” she mumbled. “I can’t afford any more tests. And, anyway, I don’t need them.” I waited quietly for her to continue.

“I know why my blood pressure is high. I stopped taking my medication a few months ago. I also stopped my diabetes and cholesterol pills, “ she stammered. “I felt ok for the first month, but I haven’t felt good for a while now.” Her eyes brimmed with tears.

“Why did you stop taking your medicine?” I asked gently.

She brightened up a little as she told me that her husband Bill finally got a job. He’d been looking for almost a year. Unfortunately, his new job meant that they lost their Medicaid because they no longer qualified. The new insurance offered by his work had a high-deductible. “We have to pay $3000 each year before our insurance kicks in,” she said. “I just can’t afford my pills and I’m worried sick that Bill might have another heart attack if he stops his.”

What could I possibly say? I silently fumed. In most civilized countries Sally and Bill’s medications would be covered. They wouldn’t have to make impossible choices.

I handed her a tissue and patted her gently on the back. “We’ll figure something out,” I told her. I knew that Sally and Bill were hard-working, proud people. It had taken a lot to convince them to apply for Medicaid when Bill’s company closed and he lost his job last year.

In the past I would have offered her “samples” to get her through this tough time. Samples were drugs provided for free by pharmaceutical companies to doctors’ offices. This is not so much a philanthropic gesture on the part of these companies as it as a means to allow their drugs to be tried out by doctors with the hope that those doctors will then be inclined to prescribe them. A few years ago, my office had a closet-full of drugs to dispense to patients hard on their luck. We were just like a pharmacy, but free.

Recently, the hospital decided to prohibit samples. There were many reasons for this. Meticulous logs had to be maintained with pertinent patient information, drug names and doses, lot numbers and expiration dates. It was difficult to keep track of all the drugs going in and out of the closet. We were a busy office. I’m sure I wasn’t the only doctor that tore the lot numbers off the box and gave the samples to my patients with the intention of logging it all in later. At the end of the day, with piles of papers to sign and notes to dictate, it didn’t always happen.

While most patients were grateful for the short-term help, many patients took advantage of this system that essentially provided drugs without co-pays. I could hardly blame them.  Rarely, a particularly entitled patient called angrily demanding medicine, even yelling at the nurses when samples weren’t ready. “I called yesterday for my Viagra! What kind of office are you running?” one man shouted to a shocked nurse.

Nurses got tired of this system as they did most of the leg work when patients called requesting samples. They filled out the logs and brought them to the doctor to sign. They called patients to tell them when their drugs were ready. They even called the pharmaceutical representatives (“drug reps”) to request specific samples when needed – all crammed in between normal duties of caring for patients in the office.

Over time sample closet rules became even stricter. Doctors were required to physically hand samples with printed instructions directly to patients. This wasn’t a problem for patients who were being seen for an appointment, but became a challenge for the ones who phoned every month for their samples. Instead of running for a bathroom break between patients, I’d be called to hand a waiting patient their samples.

My nurse coordinated the hand-off as soon as she saw me enter my office. In a smooth delivery she retrieved the samples from the closet, called the patient from the waiting room and summoned me. I stepped out of my office, took the bag from her outstretched hand and placed it into the patient’s hand. Frequently, though, patients had “just a quick question” for me and I found myself in limbo in the hallway trying to listen while calculating when I might get my next chance to use the bathroom.

Although I felt bad for patients like Sally and Bill who needed short-term help, by the time the hospital decided to forbid drug samples, I have to admit, I was relieved. And the nurses were elated. It really wasn’t a very good system. Patients became dependent on newer and more expensive drugs (no companies sampled older, cheaper drugs). When these drug samples were no longer available (because the drug rep hadn’t made it to the office in a while to deliver them or the company stopped sampling a particular medication) many patients were without their drugs.

All of this would not be a problem if I could write for any drug I wanted. If samples ran out, I could just write a prescription. But I can’t just write a prescription for any drug I choose. Insurance companies compile lists of preferred drugs (“formularies”) that have lower copays for their clients, outlawing some drugs altogether. These lists change frequently as cheaper drugs are added and more expensive ones are removed. They also change as drug companies negotiate discounts and rebates with insurance companies to gain more favorable formulary placement.

Doctors (with the help of overworked nurses) fill out frustrating “prior authorization” forms or write letters for patients when a needed drug is no longer covered. Sometimes this works, but sometimes doctors are forced to change medications that patients have been taking for years.

It wasn’t always this complicated. When I first started practicing medicine, I did get to choose the medicine I felt was best for my patient. My professional judgment and knowledge of my patients was respected. I wrote a prescription and my patient took it to the pharmacy and it was filled.

Last week I wrote a prescription for liquid doxycycline for a child very ill with Lyme disease. It took the persistent parent countless phone calls to both her insurance company and her pharmacy just to understand the process of how she could help facilitate getting her child’s medicine. It took several calls from me to my nurse and a trip in to the office to fill out paperwork on my day off to ensure the medication would be dispensed. When it was finally approved, the copay was very high since it was not on the insurance’s preferred list.

I didn’t prescribe a fancy new drug. Doxycycline has been around a very long time. It wasn’t the child’s fault the pills were too big to swallow or that they didn’t come in an appropriate dose for his size, thereby requiring a liquid form for precise dosing.

What happened? How did the cost healthcare become so unaffordable for Americans? I don’t claim to have all the answers, but clearly part of it is the expense of drugs. I know it isn’t cheap to develop and test new drugs. But why are drugs so much cheaper in other countries?

Some of this cost lies in the expense of all of the middlemen between the drug company and the patient. Some of it is in the paper pushers hired by insurances to serve as roadblocks for cost containment. If the expense of receiving and processing all the individual requests by doctors for formulary exceptions alone was eliminated, healthcare costs could be channeled to actually take care of people’s health.

And some of the cost, alas, is the expense of marketing theses drugs to consumers and convincing doctors to prescribe them.

A few years before I began practicing medicine, doctors received gifts and even expensive trips from drug reps. By the time I graduated medical school, though, the gifts were reduced to pens and notepads advertising drugs. Now even these small trinkets are no longer allowed in my state, which is a good thing.

The one significant expense that has not yet been outlawed in my state is feeding doctors. And busy doctors are hungry and eager for an easy meal.

During my residency training, I was actually able to bring my husband with me to a “drug dinner” at a fancy restaurant for the small price of listening to short educational talk and hiring a babysitter. Paul and I were grateful for those cheap dates since we were too poor and exhausted to coordinate dinner out on our own. A free meal was motivating.

A few years ago the laws changed, prohibiting spouses from attending these dinners. I stopped going. Up until very recently, though, I still went to the drug-sponsored breakfasts and lunches delivered to my work. It was convenient, tasty and free. Not only did I not have to pack myself a lunch, but I often learned valuable information at these meals.

I worried, though, over reports that these sales pitches might actually influence prescribing practices. And as the cost of drugs skyrocketed and my patients struggled to afford them, I began to feel worse about my free meals. Was I indirectly contributing to the high cost of drugs?

For the last few years, I debated a lot about whether to attend lunches anymore. In my small practice, though, I was afraid that if I made a personal stand and stopped going that the drug reps would no longer bring food to my overworked staff. Although I was the target of their free meals, I didn’t feel like it was my place to choose for the entire office.

I don’t mean to vilify the drug reps, who are hard-working people often passionate about their drugs. They have not only taught me a lot over the years but they also have provided patient education materials and patient assistance programs to those who qualify. But in the highly competitive pharmaceutical market, pressures to sell drugs are great.

Recently, instead of educating me, many drug reps confronted me with statistics on the drugs I prescribed. “I know you prescribed our drug twice this month,” one said to me. How did he have access to my prescribing practices? I found it unnerving. Another asked (inevitably when my mouth was full of food), “Why wouldn’t you prescribe my drug?” And yet another, “How do you pick which drug to try first?” I began to get defensive. I didn’t enjoy being grilled about my prescribing practices during my lunch “break”.

Not long ago a drug rep casually told me how he and another rep I knew were vying for a bonus. They were so close, he told me. He just needed someone to write a few more prescriptions for his drug and he would win. Wink. Wink. Nudge. Nudge. Was he seriously asking me to prescribe his drug so he could win a prize? Maybe not, but it made me very uncomfortable.

Which brings me to my last free lunch.

I was far behind schedule after a “routine check up” had turned into a medical emergency. Despite serious medical symptoms, my patient had waited until his appointment (“I knew I was going to see you in a few days”) to be seen. He couldn’t afford the extra copay for an additional office visit. For the past week, Robert experienced shortness of breath so severe that he couldn’t walk more than a few feet without becoming light headed. I suspected a blood clot in his lungs, which was later confirmed when he reached the ER.

After the rescue squad whisked my patient away, I rushed breathlessly to lunch, apologizing to the drug rep that I had to eat-and-run to be ready for my full schedule of afternoon patients.

I sat down with my plate full of food, shoveling in mouthfuls as the drug rep flipped through brochures in front of me that explained why his drug was superior to the rest. I nodded, glancing frequently at the clock behind his head. I answered his probing questions politely between mouthfuls. In record time (I had become very proficient in speed eating during residency) I finished my food and pushed my chair back.

The rep took no notice and kept talking. He opened up his computer to flash me more data. My feet rapidly tapped the floor under the table, willing me to run to my office so I could at least finish one dictation from my crazy morning before the next round of patients. I pushed my chair back a little further. I tried to be polite. I knew some of his show was for his manager, sitting across the table from me.

When he still ignored my not-so-subtle body language, I waited for him to take a breath and said, “I’m really sorry, but I had an emergency this morning and am very far behind so I have to get going,” I stood up.

I took a few steps away from the table. He leapt up and blocked my path. He actually stood between me and the exit from the lunch room. “Let me just show you this one other drug real quick,” he said. Before I had a chance to refuse he had opened a new brochure and began pointing to pie charts and graphs.

I was speechless. There was no escape. He rattled on. I resented him for forcing me to be rude, but I finally had to interrupt him. “Thank you again for a delicious lunch, but I really have to go now.” Before he could stop me again, I stepped around him and darted out the room.

I admit I felt some relief. Finally, someone had pushed me to the decision I had been mulling over for years. I was done with drug sponsored lunches.

I know my decision alone will not directly impact the high cost of drugs, but at least when I commiserate with Sally about the outrageous expense of medications I won’t feel like I am part of the problem.

After all, there is no such thing as a free lunch.

Baby Steps

I knocked briskly on the exam room door and slowly cracked it open to avoid potentially colliding with a child on the other side. My caution is unnecessary, though. There were no other kids in the room besides Chelsea, and she was not a typical 8 year old. She sat perched on the edge of the exam table, right where a patient is supposed to be.

Chelsea smiled brightly at me, swinging her pink-stockinged feet. She threw her hands up in the air. “It’s my doctor!” she said so enthusiastically that for a moment I had to check my own excitement.

Chelsea wore a frayed, well-loved green dress that I knew she picked out just for her well-child check up. Her pigtails were askew. Her stockings had holes in the knees. Still, I admired her effort.

Chelsea’s mother smiled up at me with tired eyes.

“Where is everyone?” I asked the precocious child in front of me. I had made the mistake in the past of directing my questions to her mother, which Chelsea took as an insult to her maturity.

“Dad took the boys and grandma has the baby,” Chelsea answered. I glanced over at her mother. Dad had been out of the picture for a while. Her mother stared stony faced at the hands in her lap.

I looked back to Chelsea whose rounded cheeks were as rosy as if she just came in from a bike ride. I was pretty sure she didn’t own a bike.

“Any complaints today?” I asked. Chelsea’s mother shook her head as Chelsea listed her concerns. “I have a bug bite on my arm. It could have been a tick – yuck! I also scraped my knee and sometimes my belly hurts after dinner. I grew an inch and grandma said I should get a flu shot because mommy is having a baby!”

I looked to her mother, surprised. “Congratulations! Maybe you should make an appointment on your way out so we can catch up?” I suggested. She nodded.

Chelsea’s exam was entirely normal, except for her BMI. She slipped from overweight to obese since her last exam. While her soft rolls and chunky thighs were endearing as a baby, her weight had become a health threat. Obese kids were much more likely to become diabetics and were at higher risk for a number of other potentially lethal diseases.

chunky foot

I also I knew that as Chelsea got older her peers would tease her about her weight, eroding away the sweet confidence and self-esteem that made her so charming.

It was a delicate subject to broach but an even more difficult one to treat. Chelsea’s mother was also obese, as were all of her siblings. The only skinny one in the family was grandma, who chain smoked and enjoyed her high-balls in the afternoon.

“Looking over Chelsea’s growth chart has me concerned,” I started tentatively. Chelsea tilted her head and squinted her eyes at me inquisitively. Her mother looked at me blankly.

I tried a slightly more direct approach. “Her weight is too much for her height.”

Her mother sat up and snapped, “I know! I told her to lay off the soda and chips or she’ll be fat. I told her she should be on a diet.” I didn’t want to lose the battle with her mother by immediately confronting her with the obvious. At 8, Chelsea didn’t have the means to purchase those things herself.

“With kids, it’s better to focus on being more active and choosing healthier foods than to actually ‘diet’,” I explained to mom. I elaborated on the ways she might help Chelsea become more active such as limiting screen time to 2 hours a day, encouraging her to play outside and letting her join in extracurricular sports.

“I wanted to play softball, but mommy wouldn’t let me!” Chelsea said crossing her arms over her chest and glaring at her mother.

“I can’t get her to the field,” countered her mother, “and I can’t expect her little brothers to sit on the sidelines for hours.”

I knew that Chelsea’s mom struggled just to put gas in her tank. I knew she couldn’t afford a babysitter and that sometimes the TV and iPad probably served as one so she could have a little break herself.

There were no parks near Chelsea’s house out in the country.  She didn’t get much exercise at school either since gym classes were scaled back with budget cuts.

“I would love to see Chelsea increase her fruits and vegetables and limit the junk food,” I said.

“I love fruit!” Chelsea shouted. “Mommy never buys it!”

“They don’t give that stuff out at the food pantry,” her mother said. “I can’t afford those expensive things.” I can’t argue that. The cheapest way to feed a hungry family is pre-packaged carbohydrate-rich foods. It’s also the easiest way for an exhausted parent to feed picky kids.

“Maybe the best we can do right now is to focus on the things that aren’t so hard to change,” I suggested. I looked at Chelsea, “Except for maybe on special occasions, I’d like you to stop drinking sugary drinks like soda and juice.” Chelsea pouted a little, but nodded her head in agreement.

I looked at Chelsea’s mom. “This would be much easier for her if you didn’t buy them at all,” I said gently. I added, “It would work best if the whole family changed a few things.”

I looked at Chelsea, who was listening intently. “Do you have any other ideas about being healthy?” I asked.

“I could play tag with my brothers?” she asked. I nodded, encouraging her to continue. “Maybe I could not sneak cookies upstairs?” Her mother’s eyebrows raised.

“Yes,” I agreed.  And maybe mom could stop buying them.

I would have loved to encouraged Chelsea and her mother to start a walking program together. I could see Chelsea proudly pushing her baby sister in a stroller with her two brothers tumbling behind her, climbing in and out of a wagon pulled by mom.

I would also love to be able to offer them a healthy cooking class on a cheap budget. In an ideal world, they could pick up vegetables at the food pantry. Chelsea could track her steps with a pedometer and keep a journal of what she ate to show a dietician who would help her make healthy choices.

I settled for eliminating soda and spending more time outside.

Maybe next time I would encourage them to start a little garden on the porch.

Baby steps.

Growing Old in America

When I told my elderly patient Walter a few years ago that with his good health he could live to be 100, he looked at me horrified. “How dare you!”

At that visit I was surprised by his response, but over time my naiveté in thinking this might have been welcome news became apparent. It’s not only the physical betrayal of the body or the mounting losses of loved ones and independence that make living less joyful. It’s the isolation and fear of not knowing who to turn to for help and the guilt of not wanting to be a burden. Our very healthcare system, which should be a beacon of hope and healing to the aging, is instead frequently a source of frustration and stress.

My older patients are overwhelmed navigating the complicated new world of computers and rushed appointments. Many patients plan months in advance to coordinate rides with busy family members. They look forward to this time with me not only to share their worries, but also to brag about their children and share pictures of their grandchildren. For many lonely older people who cherish personal time with their physician, this much-anticipated visit is a disappointment. Sifting through piles of medications while repeatedly steering the conversation back to health issues takes precedence over socializing.

And, truth be told, my older patients really don’t want all those medications that make them feel bad and that they can’t afford on their fixed incomes. Many elderly patients take more than a dozen medications, collected from multiple specialists focused on one organ. When I attempt to prescribe another pill my patients often fight me, transforming what could have been a pleasant conversation into a battle of wills.

“I feel fine!” they insist. I try my best to explain the virtue of pills that can reduce the risk of heart attack and stroke while inwardly struggling to convince myself that the potential benefits outweigh the side effects likely to be endured.

And yet, I know that a stroke can be devastating to an active and independent person. In an instant, simple tasks taken for granted like getting dressed, eating and using the bathroom in private can become impossible. Or worse, some lose the ability to communicate with loved ones. Some are unable to walk.

I also know that preventative medication can make my patients feel achy and tired, reducing the good quality of life they currently enjoy.

And then there is the prohibitive cost of many drugs in a country that doesn’t provide it’s most vulnerable citizens affordable and comprehensive healthcare. The expense sometimes causes patients not to fill the prescriptions I write. Others split pills in half or take them every other day to make them last longer. I can’t help but wonder if this self-adjustment of dose is even enough to reap any benefit?

My elderly patients also don’t want more tests that may find something else that needs treatment and may not be covered by insurance. What they really want is a quick check up and someone to listen to their fears about their loss of independence when they can no longer drive safely. They want someone to help them navigate their deep grief over deceased loved ones. They want to share their worry with me about the very real possibility that they may spend their last days in a nursing home. They lament the old times when people died quietly in their homes surrounded by family and supported by their trusted family doctor.

Walter recently came back to the office to follow up on new medication I started. Although I really liked Walter, a part of me dreaded seeing his name squeezed into my already packed schedule of patients. He was an interesting man who liked to talk (but only after asking after my own health, what my sons were doing, and whether Paul was working on any interesting projects).  I knew his appointment would put me further behind.

I didn’t want to interrupt Walter to rush him out the door (again). It was impolite, if not downright rude. I couldn’t fathom showing such disrespect to my own grandfather and could imagine his indignant protest if anyone attempted: “I’ll go when I’m good and ready and not a moment before!”

This would not be Walter’s response, though. He would respectfully allow me to guide him to the door, “They keep you too busy here! You are overworked. You need a break!” he would say with genuine sincerity as he shuffled out. Unfortunately, as doctors are forced to cram more people into crowded schedules, ushering people out has become a regular part of my job.

It isn’t just the rushing out the door, though, that bothers me with this particular patient. There is also the fact that, like many people, as he ages he develops more health problems that I am compelled to address. When he became my patient almost 10 years ago, he was taking a blood pressure medicine, an aspirin, and eye drops. We had more time back then to socialize. A few years ago, despite his relatively good health, he had a heart attack. He was discharged from the hospital with six new medications. Then, at our last appointment after routine blood work, I found that Walter was not only a little anemic but also had developed diabetes.

This presented me with a treatment dilemma. Walter had been complaining of fatigue for a long time. Multiple medications, high blood sugars and anemia can all cause fatigue. Diabetes also increases the risk for heart disease and stroke. Walter had already had a heart attack, and I knew that his youthful spirit would not survive a stroke.

In some older and debilitated people, it is reasonable to treat less aggressively. Despite his age, though, Walter still had a lot of life left in him. And so I started him on (another) medication, set him up with a dietician and requested that he submit stool cards (to make sure his anemia wasn’t from gastrointestinal bleeding).

When I entered the room I was greeted by a beaming smile. Despite his nearly 90 years, in his own mind Walter felt like he was 20. His body, however, betrayed his age with increasing boldness over the last 5 years. As if he could read my thoughts he proclaimed with conviction, “My mind is all there! It’s my body that gives me trouble. I take out my hammer and my tools and by the time I get everything ready, I’m exhausted and have to sit back down.” He shakes his head in disbelief, looking to the floor.

Like a good patient, though, he did everything I requested at his last visit. He brought back his stool cards (which, thankfully, were negative for blood), started the new medication I prescribed, saw the dietician and even remembered to bring in the carefully written recordings of his blood sugars for my perusal.

I asked him about the visit with the dietician. Did he bring his wife Joan along? A mischievous smile spreads across his face, his lips pressed tightly together as he shakes his head. “Doesn’t she do the cooking?” I asked.

He confirmed, with a sly smile and confessed “I do like to have a muffin in the morning. Don’t you think its OK for me to have a muffin?” I couldn’t help but smile.

“Truthfully, I think a man your age should eat whatever he wants for breakfast,” I said. After all, Walter had done pretty well for himself for nearly a century.

“There ought to be a cut-off age for treatment!” he blurted out. Then, just as quickly, his eyebrow creases deepened and his face grew serious. “No, not really. I know. Everyone is different.” He was almost whispering, and I knew he said this just to protect me, his potentially overly-aggressive primary care doctor. He was quiet for a minute.

This would have been a good time for me to talk about advanced directives, a discussion that I (like many physicians) was wary to broach. I also could have talked about what might happen if we decided to stop some of his medications. I could have let him know that he is ultimately in charge. The truth is, though, I didn’t want him to stop his medications. Even though I new he might feel better, I was afraid of what might happen.

“Don’t you ever get tired of all this?” he asked, waving his arms around the room. I sighed and admitted to him that sometimes I did.

“But I never tire of taking care of you,” I said. I stepped gingerly over the professional line and took a seat beside him, putting my hand on his cracked and wrinkled hand. I confided, “You remind me a lot of my grandfather”.

Screen Shot 2017-04-23 at 7.56.05 PM

The Boardwalk Brawler and his Bride

He looked up at me, eyes shining. “Really? What was he like?” I told him my grandfather was a big and strong man with a warm and generous heart. I shared with Walter how he got the title of “Boardwalk Brawler” when he was in his 70s after chasing a punk teenager who made a derogatory comment toward his beloved wife (that he lovingly referred to as his bride). You didn’t mess with Poppy, but you really didn’t mess with Grandmom.

“What happened to him?” he asked, eyebrows furrowed, leaning toward me. I explained that my grandmother (who he had courted since she was 12) got sick and soon after died. His eyes widened and he nodded his head knowingly. “He had nothing to live for,” he said quietly. I nodded in agreement, knowing he was probably thinking of his own wife and their long marriage. We sat together in comfortable silence for a few moments. Poppy barely lasted a month after Grandmom died.

I took a breath and steered the conversation back to him. I suggested he try some form of exercise, knowing he used to be physically active and was happier when he was. He looked down at his protruding belly. “This just isn’t right,” he said pointing to his stomach and shaking his head. “I don’t know what happened.”

I nudged him. “You know, we could probably stop some of your medication if you got into a regular exercise routine. I think you would feel a lot better, too.” We talked about activities he may be able to do in his frailer state.

Despite the certainty that I was now well-behind schedule, I was reluctant to leave the room. I really felt like I was talking to my grandfather, who I had missed greatly over the past few years.

“Remember when you told me I might live to be 100?” he asked me. I nodded, smiling. “I’ve been thinking about that lately. Why would I want to live to be 100?”

I admit, I didn’t have a good answer.

From the moment I heard about the Women’s March, there was never a question about what to do.

I was going to Washington DC.

Just a few months earlier as I filled in the bubble on my ballot sheet on election night, my eyes unexpectedly filled with tears. Could it really happen? A woman in the White House?

It was just too good to be true.

The morning after the election I stood outside my youngest son’s door trying to stop tears of a different sort. How could I wake him to the news that America chose a leader who spoke openly against Muslims and Mexicans? How could I explain that the idea of a woman reaching the highest office in our country was so unthinkable that we chose an inexperienced bully?

I became a doctor because I wanted to help people. I’m lucky because I get to do this every day when I go to work. My job has been more challenging recently, though. Fear and the threat of violence have a significant impact on mental and physical health. My patients complain of escalating levels of stress, which makes just about every health condition worse.

It no longer felt right to remain quietly in my safe bubble. I have no fear of being shot or harassed for the color of my skin or for my religious choices. I have never worried when my next meal would be. I have always lived in a comfortable home with my loving family.

I am white.

I left work early the Thursday before the march and drove to Delaware to pick up my younger sister. Together we headed down to my dear high school girlfriend’s house in DC.

On the day of the march, my girlfriend hosted a breakfast party. We met new people and shared our stories (and pink hats). My sister’s husband, sons and mother-in-law (who walks with a cane) drove down to join us for the march.

We set off on foot, smiling and waving at strangers wearing pink hats who were instantly transformed into friends by our common endeavor. Several dozen Canadian women passed on the other side of the street. I was impressed. They traveled far to show solidarity with their American neighbors. We stopped to take a picture of a young girl carrying a sign. Together we are one!  We gave her one of the extra hats we had made. Her joyous reaction was infectious.

I carried only my camera (with an extra zoom lens in my jacket pocket), $20 and ID (in case we got thrown into jail). I didn’t realize that we wouldn’t get back to my girlfriend’s house for nearly 10 hours. We didn’t bring food or water. (Though in the excitement, I didn’t feel hungry or thirsty all day). I followed the rules, which were clear: no backpacks. (Many people carried bags. No one checked).

The streets swelled with people until we were packed tightly together, moving as one in the same direction.

When we reached our destination, we stood in the peaceful throng of people for hours. We smiled and thanked policemen, who smiled and thanked us back. We talked to people from all over the country. Despite long bathroom lines and several delays before the march began (due to the unexpected amount of people) everyone was smiling and laughing. 

I found my tribe.

When we finally began to move, a voice shouted “Show me what democracy looks like!” The crowd yelled back “This is what democracy looks like!”

This is what democracy looks like.

img_2341

Me

I thought I was marching for women and minority rights and for healthcare, but as I moved through the beautiful crowd admiring the signs, I realized I was marching for so much more. Climate Change is Real. Honor earth.

Women’s Rights are Human Rights.
I marched for my mother and grandmother and for my sisters and girlfriends. I marched for my future daughter-in-laws and granddaughters. Many of the messages people carried seemed to come straight from my heart. We are so much more alike than we are different.

Some signs were irreverent. Vaginas brought you into this world, vaginas will vote you out! Some were thought-provoking. We cannot succeed when half of us are held back. Many were pro-choice. No woman can call herself free who does not own & control her body.

Some marchers were grandparents pushed in wheelchairs – activists who were clearly not at their first march. I can’t believe we still have to protest this shit read one sign. The 1950s are calling… do not answer!

A baby boomer held up a sign that read  My arms are tired of holding this sign since the 70s. Another had a sign that read Women are people. Really!!!

There were mothers (and fathers) holding signs and holding children. Here’s to strong women: may we know them, may we be them, may we raise them. One woman held a sign high and proud that read Granddaughter of all those witches you could not burn.

College-aged women marched. Yes she can. High schoolers marched. Girls just want to have fun-damental rights.

A little girl perched on her father’s shoulders held a sign that read A woman’s place is in the house, and the senate. Her baby brother’s sign read Be a buddy, not a bully.

img_7583

Without Immigrants there would be no America!
I married an immigrant, opening my small world to a whole beautiful other culture. His brave parents sought asylum in America to escape communism. America is a better place for their arrival and for the immigration of countless other scientists, engineers, educators, doctors and parents trying to make better lives for their children.

I marched alongside a beautiful girl carrying a sign that read Proud & Powerful Daughter of Immigrants. I wanted to reach out and hug her. I wanted to let her know that not all Americans are bigots, but the crowd moved swiftly around us and she was soon out of reach. I didn’t need to tell her anyway. We were embraced in the arms of a community that would stand up for her and her parents.

Several marchers scattered in the crowd carried signs that read Say No to a Muslim Registry. A year ago, the need to carry a sign like this in our country could not even be imagined. We marched under a bridge where a crowd of people were gathered cheering us on and waving signs. Build Bridges, not walls.

img_7353
Diversity is beautiful
Many people marched in support of the persecuted. Must be nice to look past sexism, racism and homophobia because it won’t ever affect you. But it actually will affect you if you aren’t a man, if you aren’t white, if you aren’t straight or if you happen to have any women, non-white or LGBTQ friends or family.

Most of the messages were positive: We rise by lifting others.  Respect ALL people NOW. Human dignity for all.  End civil wrongs.

img_7690
For much of the march, I was quiet. But when the crowd started chanting “Black Lives Matter!” and I heard my young black nephew next to me shouting the words, I didn’t hold back. I couldn’t look at him, though, in part out of shame that we even needed to say those words and in part because I thought I would fall apart. It didn’t matter. Tears rolled down my cheeks anyway.

When the chant was over I looked over at his mother, my sister, who was also crying. I reached over and squeezed her hand as I smiled at my nephew through my tears. I will keep fighting for you, my love.

love-one-another

Me Kissing my Nephew

Make America Kind Again

Americans were duped by 4 words: Make America Great Again.

Like when Jim Crow Laws were enforced? Like when poor people died of treatable conditions because they had no access to healthcare? Like when a woman’s place was in the kitchen? Like when businesses freely dumped pollutants into our waterways and we were carefree and ignorant about global warming?

Were Americans nostalgically recalling the good old days when a person’s religion or country of origin could at best exclude them from jobs and housing and at worse cost them their life?

One of my favorite chants of the march was “Love, not hate, makes America great!” We don’t need to make America great again. In Our America: All people are equal, love wins, black lives matter, immigrants & refugees are welcome, disabilities are respected, women are in charge go their bodies, people & planet are valued over profit, diversity is celebrated.

Disarm hate.

One of the most amazing things about the march was the emphasis on love and a peaceful resistance. Despite the large and passionate crowd, not a single person was arrested. We marched packed closely together, a community of tolerance and love. People smiled at one another and actually made eye contact.

Martin Luther King was quoted repeatedly: Darkness cannot drive out darkness, only light can do that. Hate cannot drive out hate, only love can do that.

Messages of love were everywhere: Love is Love is Love is Love is Love. Let us see what love can do (William Penn). Legitimize Love. Love more. Love harder. Unite with love, resist with love. Love one another. Be kind to one another.

Nothing can dim the light that shines from within.

Challenge accepted
I am no longer accepting things I cannot change, I am changing things I cannot accept.

Many marchers carried signs to inspire others toward activism:
Freedom is in Peril, Defend it with all your might.
If you don’t condemn, you condone.
Let our power ripple out, the fight has just begun.
Rise up.
Respect existence or expect resistance.

Others encouraged people to use their brains (Think: It’s not illegal yet) and their voices. Your silence will not protect you. Silence is consent.

The power of the people is stronger than the people in power.

I’m not a sore loser, I’m an informed citizen.

There were messages to other countries: Sorry World.

Before the march I felt hopeless and disappointed in my country. As I looked around at the passionate people surrounding me, though, I felt so much better. These people were not going to give up. They would not stop fighting. This was more than a 1-day march, it was the beginning of a worldwide resistance against hate and intolerance. I would not go home and forget. I would not let my tribe down.

As we got closer to the White House, people began to chant: “We’re not gonna go away – welcome to your first day!” Signs were directed to the POTUS: Don’t make America sick again. Integrity matters. People over profit. Words Matter.

img_7887

As my sister and I left the march and moved away from the piles of signs, we passed a lone message left against a tree.

img_7903

This is our challenge.

Caregivers

 

Caregivers!.png

Buster & Digby feeding Orion

Sally glanced at her watch for the third time and then looked expectantly at the door. Her foot tapped nervously against the exam table. She let out a sigh.

“I’ll come back for my blood work in a few days,” she said over the keyboard tapping as I entered my orders into the computer.

“Whenever it’s convenient for you,” I answered. “I’ll order your mammogram and bone density, too. They’ll help you set that up at check out.”

“Can I call later about scheduling those? I have to go now!” she blurted out.

I looked up from my screen, surprised by her outburst.

“Sally? Is everything ok?” I asked. She hadn’t offered any complaints during her exam, but she did look tired tired. Exhausted, even.

“Sorry,” she said. “Joe is in the car.”

I nodded in understanding. Her husband Joe was diagnosed with Parkinson’s dementia last year. He suffered a particularly progressive course, quickly escalating from forgetfulness to an inability to care for himself at all.

“He’s fine, really. He doesn’t even remember how to open the door,” she said with a nervous laugh. Then, more seriously added, “I had no choice. I can’t leave him at home alone.”

I urged her to go to him and reassured her that my office would contact her to set everything up. I told her that next time she has an appointment she should bring Joe in with her. “This is a Family Practice. Joe won’t be any more distracting than the toddler perched on his mother’s belly this morning during a Pap smear!” I joked, hoping to make her feel better.

Six months later she returned for a follow up after rescheduling multiple times. She smiled at me when I entered the room, but her face looked strained.

“Is Joe in the car?” I asked, mentally checking off the things we might skip today to get her through the appointment faster.

She shakes her head and looks into her lap, her lips pressed tightly together.

“No. He’s home with a nurse. He doesn’t walk anymore,” she said sadly.  I was glad that at least she could afford to hire part-time help, unlike many of my patients.

She told me about the last time she took him out by herself to a doctor’s appointment. She practically carried him to the car. She had to call a neighbor to help get him out when she got home.

I listened, wide-eyed. She was a slight woman and Joe was a big man.

“Are you thinking it might be time to take him someplace where he can get more care?” I asked softly.

She shook her head vehemently. “I’m fine! Really, we’re ok. I have some help now so I can sneak out to the grocery store,” she said. She quickly added “and to my own doctor’s appointments.”

I knew it was difficult to find affordable help. For insurance to pay for a visiting nurse, patients had to meet strict criteria. First, a doctor had to certify that they were “homebound” and unable to get to the office without significant distress. Then there had to be a billable “skilled nursing” need, which was usually not the true reason for the referral.

Sometimes I managed to get a nurse into a home by declaring a patient to be a “fall risk” and requesting an assessment of their safety. Sometimes ordering blood pressure or blood sugar monitoring because of a recent change in medication was adequate. Once in the home, the need for nursing services was often obvious. But it was only a temporary reprieve. After a few visits, the “skilled nursing” duties were done and the patient was left again to fragmented care by willing family members.

Unfortunately, “caregiver burnout” did not qualify as a reason for help.

I gently reminded Sally that she still hadn’t done the blood work or any of the other tests that I ordered six months ago. I was worried that she wasn’t really taking care of herself. Who would care for Joe if she got sick?

“I do appreciate your concern, but I will never abandon my husband,” she said flatly.

I nodded at her and smiled. I already knew that would be her answer. I just wanted to let her know it was an acceptable option, just in case. I imagined myself in her shoes. Sally held on tightly to the memory of a deep love that was heartbreakingly absent in her husband’s blank face.

It is never easy letting go.

I wish there was something more our healthcare system could offer her than the choice to struggle at home, becoming an expert at nursing care, or putting a loved one in a nursing home. Surely it would be more cost-effective to provide services to people who wanted to keep their family members with them as long as possible. At least in Joe’s case he was blissfully unaware of the struggle. He would have never wanted Sally to suffer.

I thought of Liz, another patient of mine who made similar sacrifices for a loved one. Her mother went blind, one eye at a time, in rapid succession. In a matter of days Liz, a successful artist and mother, was forced to undergo her own major transformation. Just as she was beginning to get comfortable in her new role as a mother of grown children, she was hurled back into parenthood, but this time to her own struggling mother.

Although her mother lived several states away, there was never a question for Liz of bringing her mother to live in Upstate New York. It was unthinkable for her to take from her mother what little she had left: the familiar comforts of a home where she had raised her children and lived peacefully with her husband for decades.

To uproot her mother and plant her in an unfamiliar place to navigate in the dark would be cruel. Despite the complexity of the arrangement, moving in with her mother and traveling back to her own home and business (when she was able to find someone else to stay with her mom for a few days) was the only possible solution.

I remembered Liz’s last appointment. The stress of running a business and being a wife and mother (and daughter) in two distant places showed on her drawn face. I was concerned about her health.

When I entered the exam room I was greeted by a big smile meant to hide her exhaustion. She jumped to her feet when I asked about her mother. She wanted to share with me a short video she had made yesterday on her phone.

The small screen showed a bright, elderly woman sitting on a porch. Her wrinkly cheeks were puckered, and her concentration intense as she whistled, calling the birds to her. I watched in amazement. She sounded just like a bird. Real birds off-camera were calling right back to her. Fluttering shadows danced across her face and the wall behind her. They seemed engaged in conversation, her mother and the birds.

My patient beamed as she looked lovingly at her mother on the screen. “This is the reason I was able to tear myself away to come home for two days,” she said. “I just couldn’t leave her before this.” Her voice trailed off. I smiled and waited for her to continue.

“It was just awful. Her doctors changed her medications because she wasn’t sleeping but the side effects were terrible. She just wasn’t herself.” She paused. “The medications actually made her suicidal,” she said, her voice dropping to a whisper. I touched her hand and told her I was so sorry that she had to go through this alone and so far from home.

“Actually, I am really lucky,” she said, bringing her hands to rest protectively to her belly as if cradling a baby. “Remember how you felt when you were pregnant?” she asked. I nodded. “I feel that way now,” she said. “I’m living outside any normal routine. When I was pregnant, everything I did was in anticipation of this beautiful life to come.”

She looked down at her slim lap for a moment, lip trembling. “Now, everything I do is also in anticipation. This time, though, I’m expecting the opposite. I am preparing me and my mother for her departure.” She took a deep breath and sighed. “I feel so blessed to have this time with her to get us both ready.”

I remembered my own mom curled up next to my grandmother in her bed during her final days. I imagined my grandmother wrapped snugly in the quilt my mother had made for her. I was so grateful that my mom was able to be with her and hold her while she breathed her last breath. I hoped I would be there for my own mother when the time came. It was a beautiful closure – a new mother cradling her infant as she takes her first breath and then that same infant holding her mother as she takes her final one.

The room was quiet as we sat together in thought. She smiled at me and broke the silence. “What are we going to do without daughters? Who will take care of us when we are old?” she asked with a wry smile. (We both have only sons.)

“I’m hopeful my boys will take care of me,” I said optimistically.

“I’m going to work on their partners!” she replied with a laugh.

I wanted to tell her that the sacrifices she made would be worth it in the end. I wanted to tell her everything would be ok. I wasn’t entirely sure I believed this myself, though. I saw so many people become sick while caring for family members. Most times, it was the wives and daughters who took on this role. I wondered if I had a daughter would I really want her to make those sacrifices?

There is no right answer. Every situation is different. People do what they think is right, and I would never presume to know more than my patients do about their personal circumstances. I will, though, share my concerns if I think their choice is negatively impacting their physical or mental health. I will also share my opinion if asked. I try to support my patients when they’re overwhelmed and exhausted but also to also let them know it is ok to let go when they just can’t do it anymore.

I didn’t share all of these thoughts with Liz, though.

Instead I told her, “Your mom is a very lucky woman.” And I meant it.

Repeal & Replace: Take Insurance Away from Millions & Pay Cash for Your Healthcare Bills

Bob came to the office this week for a follow up of an abnormal CT scan of his chest after suffering several bouts of pneumonia over the past year. He complained of constant shortness of breath. He couldn’t lay flat in bed at night. His lung doctor believed that his symptoms were made worse by occupational exposure to chemicals in the factory where Bob has worked for over 30 years. Not surprisingly, this doctor suggested he find different work. I asked Bob if he was going to do that.

“Who is going to hire a 60 year old with lung problems?” he asked. “If I don’t work I lose my insurance. I can’t retire for a few more years.”

In a single payer system Bob would not have to stay at a job that is killing him so that he could afford the tests and treatments he must undertake because of that very job.

More than ¾ of people who declared medical bankruptcy had health insurance at the onset of their illness or injury but lost coverage when they were no longer able to work. Bob is tied to a job that not only affects his quality of life, but is likely shortening it.

It is time that the United States join all other developed countries in the world and demand that health care be declared a civil right for all citizens regardless of employment or health status.

I saw Ellen the same day. She was very sick. Her blood pressure was also high. When I asked her why she wasn’t taking the blood pressure medicine I prescribed at our last visit she told me she planned to pick up the prescription this Friday after she got paid. She didn’t have the blood work done that I had ordered either. She explained apologetically that her deductible was too high to do her blood work right now. The mammogram I ordered 6 months ago would have to wait too.

Like many patients, Ellen is underinsured. High deductibles and co-pays prevent her from using her insurance. She doesn’t come to the doctor unless she is very sick. Because she is not taking the medication prescribed or doing the tests that were ordered she is labeled “non-compliant” – not following her doctor’s advice. But whose fault is that really? How long will it take her to become more seriously ill?

Ten years ago, fewer than 10 percent of people with health insurance had a plan with a deductible greater than $1,000. Today that number is 46 percent. Nearly half.

The paradox of our current health care system is that it is based on avoiding the sick. Insurance companies compete not by improving quality but by avoiding unprofitable patients and by shifting costs back to patients with higher premiums and copays. In other words, the rising costs that result from our population becoming sicker are simply charged back to us.

Opponents to a single payer system argue that they don’t want the government interfering with their health because they are afraid that they will lose control over health care decisions. It is a delusion to think that we actually have control in our current health care system. Patients can’t pick their doctor or hospital of choice. They must chose from a list of on-network providers determined by their insurance. Doctors don’t control the medications they prescribe – this is a deal worked out between the insurance company and the drug companies. Doctors don’t even have control over the tests they are allowed to order. Insurance companies decide what they will pay for.

As a doctor, I long for the day that I can treat my patients based on my own professional judgement from years of training and caring for patients, not based on what insurance companies will cover or what my patients can afford to pay out of pocket.

People fear what they don’t know. They worry that a single payer system would be one step closer to allowing “socialized medicine” into this country. But socialized medicine is where the government actually owns and operates the medical system. Single payer is public healthcare insurance and financing not healthcare delivery. Essentially it is “Medicare for all” (which surveys show has 2/3 of Americans support as well as the majority of medical professionals). In a single-payer system, medical experts oversee their peers – not private corporations like insurance companies.

A single payer system would prevent price gouging by pharmaceutical companies. It would also streamline the astronomical administrative costs that result from doctors and hospitals trying to navigate for-profit insurance companies’ ever-changing rules. It would eliminate so many of the obstacles to care erected by insurance companies seemingly to make patients and doctors crazy.

But what about the possibility of having to wait in long lines and not being able to get needed tests? All healthcare systems ration resources, but in our country we ration based on ability to pay, not medical need. We are deceiving ourselves if we believe that we don’t already have long waits – we wait for unprofitable forms of care such as primary health care, mental heath and ER visits. How easy was it for you to get an appointment with your doctor the last time you wanted one? Have you ever tried to get a loved one in for counseling?

John sees me at least 3 times a year for dental infections, the unfortunate result of an impoverished childhood. At each of these visits I prescribe antibiotics and recommend that he see a dentist that he can’t afford and is not covered by his insurance. He gets better for a while but since I don’t actually fix the underlying tooth problem, he will be back. Although dental infections may seem minor, they cause John to miss work and fall further into debt. Dental infections are also associated with an increased risk for cardiovascular disease.

At least John doesn’t need substance abuse counseling or treatment for severe depression, neither of which would be covered by his insurance.

In a single payer model, all of these health care services would be covered: primary care, hospitalizations, ER services, prescriptions, medical equipment, hearing, long-term nursing care, palliative care, podiatry, mental health, dentistry, ophthalmology, chiropractic care, substance abuse, reproductive care, rehabilitation – all without co-pays or deductibles.

A single payer system would focus on prevention, the true key to improving our health as a a society. If one entity is responsible for the cost of an entire population, it is in their best interest to keep that population healthy. Also, people would seek care sooner if they didn’t have to worry about cost – before their illness became (at best) more expensive to treat or (at worse) too advanced for treatment.

Despite the many shortcomings of Obamacare, it is rare today that I see anyone in my office with no insurance (unlike the past where I saw patients every day with no coverage). The uninsured I saw were not checking in for annual physicals. They were paying out-of-pocket to come to the office so they were generally pretty sick, having exhausted all other efforts to get better on their own. They needed medicine and sometimes needed some tests. I had little to offer them that would not make their financial situations even worse.

What happens to sick people who don’t have insurance? We may find out.

If Obamacare is repealed as threatened, 20 million Americans could lose insurance. This will not only cause longer lines in the ER (where uninsured people receive most of their healthcare), but people will die. People will die. Not having insurance increases a persons risk of death by 40%.

Obamacare is not perfect. The picked apart version we have today is not a true representation of the original grand vision for change but rather the result of heated bargaining and compromise. However flawed our current version is, though, I know that all doctors want their patients to be insured.

It is not time to repeal and replace Obamacare. It is time to strengthen it’s intent on improving healthcare for all.

It is time to declare that all Americans have a right to affordable healthcare.

mountainmeditation

Dying

My cell phone vibrated on the car seat next to me. I ignored it, knowing it was a distraction that would make me even later. Besides, there was no cell service on my dirt road so even if I answered it we would be abruptly cut off.

I was on call for my practice and late for my yoga class (again). I hated being late. I tried to arrange my hectic schedule carefully but inevitably jammed in just one more thing before I left. In fact, my yoga class was really just a formally scheduled break. I always felt better after stretching and moving and breathing in a quiet space but I knew my true motivation behind going. It was a planned time to unwind. I could not do just one more thing when I was in yoga class.

My phone vibrated again. I glanced down to make sure it wasn’t my beeper that was vibrating. I would have to answer that distraction whether it fit into my scheduled down-time or not. My breath caught. It was my father. He never called this early in the evening. I pulled the car over to answer.

Before I had a chance to say hello he blurted out: “You have to go to your mother! She won’t listen to me. She won’t leave Aunt Dot’s side. She hasn’t eaten all day. She is going to make herself sick.” His tone was serious, desperate.

“Please,” he pleaded unnecessarily as I was already doing a U-turn and heading away from yoga class toward the nursing home where my Great Aunt Dot went to live when she could no longer walk.

My aunt was living in the nursing home where I see patients twice a week. She moved north from Florida after receiving a diagnosis of metastatic cancer. My parents cared for her in their home for as long as they could, but they both worked and she was challenging even in good health. As her illness progressed it just wasn’t safe. For one, she was morbidly obese. Her legs swelled and weeped fluid. My parents couldn’t lift her. As she spent more time in bed she became weaker and soon wasn’t able to walk at all.

screen-shot-2016-10-11-at-8-24-43-pm

Great Aunt Dot holding my son Orion (one of the few things that made her smile in the end)

She had also become confused, which actually made the decision a little easier for my parents. She would never had allowed placement in a nursing home if she possessed her full bossy faculties. Despite meticulous background research and extensive interviews of all of her doctors, despite never smoking or drinking, despite living a fairly pious life caring for her own mother until she passed, she was not immune. My Great Aunt Dot was dying.

I pulled into the parking lot and ran through the front doors. I waved at the nurses as I turned down my aunt’s corridor, unsure if any of the nighttime staff would even know who I was.

I paused for a moment outside the open door, not sure what I would find. I took a deep breath and went in.

My mother stood pale at the head of the bed holding my aunt’s puffy hand. She watched helplessly as my aunt’s chest heaved rapidly, small grunts escaping with each exhalation. I rushed to my exhausted mom and grabbed her hand. She looked relieved.

“How long has she been like this?” I whispered.

“All day,” my mother answered.

No wonder she wouldn’t leave her side. It was easy to conceive that each horrific grunt escaping her swollen lips might be her last. It was downright painful to stand by and watch my aunt struggling for breath. I was sad that my mother had been standing vigil alone over this depressing scene for hours.

I glanced around the darkening room. The nursing staff had thoughtfully wheeled in a coffee urn and cookie tray for my mom. A cold cup of coffee stood on the edge, my mother unwilling to let go of Aunt Dot’s hand long enough to reach for it. The cookies looked untouched.

“Did they give her morphine?” I asked, incredulous over the noise of her labored breathing which I was certain could be heard in the hallway.

My mom nodded.

“How much? When?” I asked. Her answer surprised me. She was given a very conservative dose for a woman her size and it was only ordered for every 3 hours as needed. My mom glanced up at the wall clock, which I was sure she watched all day. “Just one hour to go before she can have her next dose,” she said.

Physicians generally follow the adage “start low and go slow” when it came to strong medications like morphine. Clearly, though, it was well past the time to increase the dose and frequency. My aunt was dying of cancer and no heroics would save her now. In the evening, the decision to administer or change a patient’s medication fell to the on-call doctor.

That was me.

Maybe I was a coward. I had only been there a few minutes, but I just couldn’t stand by and watch as bravely as my mom had done for hours.  I kissed my mom and slipped back out of the room. I walked briskly up to the nursing station. I didn’t see any familiar faces, but I hoped that one of them might recognize me.  “Excuse me,” I said, hoping to sound authoritative despite my yoga clothes.

A nurse looked up at me and smiled.  “How can I help you?” she asked.

I took a breath.  “Can you please tell me what medications my aunt is getting for her breathing?”

By the sympathetic look on her face, it was clear that she knew my aunt was dying.  By her answer, it was also clear that she knew who I was.  “She is getting morphine sulfate, 2 mg every 3 hours PRN.”

“I’m actually on call tonight,” I confided, a truth that gave me the confidence to proceed.  Still, I hoped that she wouldn’t think my request inappropriate.  “I think she needs more,” I said. Two nurses nodded in unison. “She’s a big lady,” I added unnecessarily.

“What would you like, doctor?” asked the first nurse.

“Can we please increase the dose to 4 mg every half hour as needed?”  I asked.  “Starting right now,” I added. “Please.”

“Right away,” said the nurse smiling. I let out the breath that I was holding. She seemed as relieved as I was.

I jogged back down the hall to my mom, feeling bad that I had left her alone again. A moment later a nurse came in wielding a needle. We stepped away from the bed to let her by.

“Sorry, sweetie,” she said to my comatose aunt. “This might prick a little, but it will help you breathe better.” My mom squeezed my hand. The nurse whisked out of the room almost as quickly as she entered, leaving me and my mother alone again with Aunt Dot.

Within moments my aunt’s chest stopped heaving. The grunting stopped. Her breath became deeper and slower. She looked peaceful. I smiled at my mom as we moved in closer. It was much less scary to be around her now. Morphine is a miraculous drug.

My mom went to the far side of the room and crowded onto the sliver of the bed not taken up by my aunt’s hulking frame. She leaned over and whispered in her ear. “Even though I swore to you I never would, I forgive you for the way you treated my girls when I left them alone with you overnight the last time.” It was the very last time she ever sent my sisters and I to stay with her. My aunt never had any children.

It was easy to be brave and move in closer with the painful death rattle gone. I perched myself on the other side of her bed.

I remembered so clearly that last time we stayed with her. Aunt Dot forced my little sister to eat oatmeal even though she didn’t like it. My sister’s small belly was quickly overwhelmed by the big gulps of water she drank to force it down. She threw it all up. This infuriated Aunt Dot who made her clean it up and sent her to her room whimpering.

When my aunt was doing the dishes afterward, I snuck into the small bedroom to comfort my little sister.  My aunt discovered me and yanked me out hard by my arm muttering, “I just don’t know what has happened to you girls!” I felt ashamed, sure my mother would be disappointed in our behavior.

Instead, my mom was livid. She may have been the only person in who ever stood up to Aunt Dot. She told her she would never leave us with her again.  She never did.

“I forgive you for that, too” I said, feeling a weight lift off my chest. “I also forgive you for the many, many times you yelled at me for misbehaving”.  My mother suppressed a laugh.  My aunt did not appreciate my wild and noisy ways.  Children should be seen and not heard.

I pushed further onto the bed, nearly sitting on my aunt’s lap.  Together my mom and I held Aunt Dot and, like priests at her silent confession, granted her forgiveness for all her past offenses.

When we finished, we thanked her for her unexpected generosity. I thanked her for my favorite stuffed dog with the red bow tie she gave to me when I was six that followed me to college.

I thanked her for letting our busy family invade her quiet beach vacation every year. I smiled picturing her shock of red hair and green and white polka dot bathing suit. As a child I was always amazed at how carefree she floated in the ocean, her eyes closed against the bright sun, rather than frantically scanning the surface for sharks and other scary sea creatures like me. Her red hair, beach ball rounded belly and stubby feet were the only parts above water as she bobbed over the waves for hours.

I thanked her for taking us to see The Nutcracker Ballet in Philadelphia. Afterward she took us out to a fancy dinner where they served sorbet on silver platters atop giant lighted ice swans.

My mom and I laughed through out tears as we shouted over each other to tell my aunt all of the things we were grateful for.

When we were done, we both leaned in and kissed her round cheeks. A few minutes later she was gone, as peaceful as if she had gone to sleep. I felt blessed to be with my mom at her side as she slid quietly away from the life she had held on to so tenaciously.

Mostly, I was grateful to have been a part of one final gift for my aunt – a peaceful death.